The Campaign for McMaster University KT Canada National Seminar Series: Interdisciplinary Knowledge Translation in Critical Care Rehabilitation Michelle Kho, PT, PhD Canada Research Chair in Critical Care Rehabilitation and Knowledge Translation Assistant Professor, School of Rehabilitation Science, McMaster University Clinician Scientist, St. Joseph’s Healthcare Adjunct Assistant Professor, Department of Physical Medicine and Rehabilitation, Johns Hopkins University December 12, 2013

Acknowledgements Canada Research Chairs Program Canadian Institutes of Health Research I have no other competing interests

Learning Objectives Understand the state of current best evidence for interdisciplinary rehabilitation in the ICU Understand barriers and facilitators to providing rehabilitation in the ICU Identify opportunities for interdisciplinary ICU KT activities

What is the best evidence for rehab in the ICU? Learning Objective 1: What is the best evidence for rehab in the ICU?

What happens to patients after the ICU?

Long-term outcomes in survivors of critical illness

In an ICU survivor’s words… “It is hard to convey just how debilitated one is after an insult of intensive care magnitude. When I was finally weaned (from mechanical ventilation), sitting in a chair was impossible…. There was a remarkably persistent and overwhelming generalized weakness and fatigue.” Misak. Am J Respir Crit Care Med 2011;183:845-6.

Prospective 1 and 5-year follow-up study of 109 ICU survivors: Impact on function Setting: 4 Canadian ICUs Population: Adult patients with ARDS ICU Admission ICU Discharge Outcomes: Primary – 6 minute walk test Pulmonary function tests Health-related quality of life Clinical Course 3 months 6 months 12 months 60 months N=83 281 m 49% predicted 422 m 66% predicted 6 minute walk distance N=82 396 m 64% predicted N=64 436 m 76% predicted Herridge et al, NEJM. 2003. 348:683-93;Herridge et al., NEJM. 2011. 364:1293-304. 8

Prospective 1 year study of 545 ICU survivors Setting: 41 US ICUs Population: Adult pts with ARDS in NHLBI EDEN RCT ICU Admission ICU Discharge Outcomes: Primary – SF-36 (V2) Physical function domain Secondary – Physical, psychological, & cognitive function; quality of life; employment status Clinical Course Mean (SD) ICU LOS: 14(12); Hospital LOS: 22(16) 6 months 12 months Outcomes Norms SF-36 Physical Function 82(9) 51(32) 55(32) SF-36 Mental Health 76(3) 64(26) 65(25) “Substantial” PTSD 26% (122/514) 23% (107/487) Employed 52% (116/223) Needham et al., BMJ. 2013. 346:f1532. 9

Cognitive function 3 and 12 months post-ICU Median ICU length of stay = 5 days Normal Mild cognitive impairment Traumatic brain injury Alzheimer’s disease Pandharipande et al. N Engl J Med 2013;369:1306-16.

Potential KT Target: Effects of Bed Rest

Bed rest is bad for many body systems Musculoskeletal ↓ Muscle mass/ volume ↓ Muscle strength ↓ Bone density Joint contractures Impaired balance/ kinesthesis Cardiovascular ↓ VO2 max ↑ Heart rate ↓ Stroke volume ↑ risk VTE Microvascular dysfunction Systemic inflammation Metabolic/ endocrine Glucose intolerance Pulmonary Atelectasis Dermatological Pressure ulcers Gastrointestinal ↓ Appetite Constipation Psychological / Behavioral Sensory deprivation Disorientation/ confusion/ delirium Depression/ anxiety Genitourinary Urinary stasis, stones, infection http://www.londonlives.org/static/images/ecorcheWell.jpg Am J Phys Med Rehabil. 2009. 88:66-77; Crit Care Med. 2009. 37(Suppl.): S422-S428. Med Sci Sports Exerc. 1997. 29(2): 197-206.

Muscle changes >10% in the 1st 7 days of bed rest in the ICU Puthucheary et al., JAMA. Published online October 9, 2013.

For every day of bed rest in the ICU, patients are 11% weaker 2 years later Fan et al., Crit Care Med. 2013. Published online November 15, 2013.

Potential KT Target: Effects of Delirium

Delirium is NOT “normal” for ICU patients Signs & symptoms: Change in level of consciousness Abrupt onset & fluctuation during the day Inattention Change in cognition &/or perception: Impaired short-term memory, word finding, orientation Illusions Hallucinations – often visual, but may be auditory or tactile May have delusions, disorganized speech, emotional lability, sleep-wake disturbance All in the absence of a psychiatric condition Adapted from DSM IV-TR, American Psychological Association 2000

Epidemiology of ICU Delirium Hypoactive delirium Mixed delirium Hyperactive delirium 44% 55% 1% Sleepy, inattentive Decreased motor activity Agitated Increased motor activity 20 - 80% of ICU patients develop delirium at any point Frequently unrecognized or misdiagnosed by clinicians Typical onset in ICU patients: Day 2 ± 2 days Typical duration in ICU patients: 4 ± 2 days 50% and 10% of ARDS patients delirious @ ICU and Hospital d/c Ely et al. JAMA 2001. 286: 2703-10.; Ely et al. CCM 2001. 9:1370-9. Paterson et al. JAGS 2006. 54: 479-84.; McNicoll et al. JAGS 2003. 51:591-98. Fan et al. CCM 2008. 94-9.

Consequences of ICU Delirium Higher mortality1 Longer duration of mechanical ventilation1 Longer ICU & hospital length of stay1 Higher ICU costs2 Poorer physical function 1 year post-ICU3 1Ely et al. JAMA 2004. 291:1753-1762. 2Millbrandt et al. Crit Care Med. 2004. 32:955–962. 3Brummel et al., Crit Care Med. 2013. epub ahead of print Oct 23.

Summary: Why is rehab in the ICU important? After ICU, patients are at risk for: Physical impairments Cognitive impairments Potential rehabilitation targets: Bed rest: The 1st 10 days of bed rest are crucial Muscle volume and strength losses Delirium

What is the evidence for rehab in the ICU?

Outcome # Active Mobilization Safety 10 No serious adverse events requiring life-saving measures Muscle strength 6 Inconsistent results, but not worse Walking 3  6 minute walk test or walking distance ADLs* 4 Improved Mechanical ventilation 9 6 no difference, but not worse 3 shorter duration Length of stay 7 No difference in RCTs Non-RCTs, reduced ICU and hospital LOS *ADLs = Activities of Daily Living Li et al., Archives of Physical Medicine and Rehabilitation. 2013. 94:551-61.

RCT of early PT/OT in the ICU Primary Outcome: Independent functional status @ hospital discharge (composite) (6 ADLs + independent walking) Medical ICU R Daily interruption of sedation + Early OT/PT 7d/wk N=49 Daily interruption of sedation + Standard care OT/PT N=55 59% (29/49) p=0.02 N=104 35% (19/55) Schweickert et al., Lancet. 2009. 373: 1874-82.

It’s about receiving therapy while on mechanical ventilation Intervention PROM -> AAROM -> AROM -> Bed Mobility -> Transfers (sitting) -> Sitting balance -> ADLs -> Transfers (standing) -> Ambulation Intervention N=49 Control N=55 Median time to start therapy (d) 1.5 [1.0 to 2.1]* 7.4 [6.0 to 10.9] Median duration of therapy (h/d) During MV 0.32 [0.17 to 0.48]* 0 [0 to 0] During no MV 0.21 [0.08 to 0.33] 0.19 [0 to 0.38] *= p<0.01 0.32 h/d = 19.2 minutes Schweickert et al., Lancet. 2009. 373: 1874-82.

Patients receiving early rehab had less ICU and hospital delirium Intervention N=49 Control N=55 p value ICU delirium (days) 2.0 [0.0 to 6.0] 4.0 [2.0 to 7.0] 0.03 Time in ICU with delirium (%) 33% [0 to 58] 57% [33 to 69] 0.02 Hospital delirium (days) 4.0 [2.0 to 8.0] Hospital days with delirium (%) 28% (26) 41% (27) 0.01 Schweickert et al., Lancet. 2009. 373: 1874-82.

RCT of cycling in the ICU Primary outcome 6 minute walk distance @ hospital discharge (∆=50 m) Treatment (5d/wk) Cycling OD 20 min; passive/ active Respiratory PT A/PROM U+L/E Ambulation as appropriate N=45; median time to Rx: 14d Control (5d/wk) N=45; median time to Rx: 10d R N=90 196 m [126-329m] N=26 p<0.05 Single center Medical (n=19) Surgical (n=71) 143 m [37-226m] N=32 Burtin et al., Crit Care Med. 2009. 37(9): 2499-2505.

Pilot RCT of early physical and cognitive therapy Primary outcome Tower Test @ 3 months post-ICU Group 1 Cognitive Therapy + Early PT N=43 10.0 [8.0-11.0] N=18 R N=87 Group 2 Early PT N=22 11.0 [11.0-12.0] N=14 p=0.20 Control Usual Care N=22 10.0 [8.8-12.0] N=12 Single center Medical (n=53) Surgical (n=34) Normal = 7 to 13 Higher scores = better Brummel et al., Intensive Care Med. 2013. published online November 21.

What are barriers and facilitators to ICU rehab? Learning Objective 2: What are barriers and facilitators to ICU rehab?

Potential KT Challenges to implementing ICU rehab Patient population Medical vs. Medical-surgical ICU Patient stability Intervention Active ingredients? Dose? By whom? Outcomes

Pre-Johns Hopkins Hospital MICU QI Setting: Academic MICU; N=32 Population: Adult patients mechanically ventilated ≥4 d Objectives: Describe frequency, physiologic effects, safety Longitudinal changes over hospitalization – muscle strength, ROM, physical function ICU Admission ICU Discharge Hospital Discharge Awake 4 Days MV Clinical Course Results: 72% rec’d referrals (n=23) Median 10 days to Ax 72% days pts deeply or moderately sedated Rx on 12% ICU days/ pt Minimal physiologic effects, no safety events 38% pts ambulatory @ ICU d/c Measures: Muscle strength Contracture index Unsupported sitting Ambulation Functional status Zanni et al., J Crit Care. 2010 Jun;25(2):254-62.

Barriers to implementing ICU rehab: understanding the process and context of work Staffing: Time requirements and adequate staffing Need for staff training Need for team work and coordination Safety: Dislodgement of devices (CVC, ETT, feeding tubes) Worsening gas exchange Unstable hemodynamics Sedation: Over-sedation of ICU patients Inadequate patient comfort, pain control Zanni et al., J Crit Care. 2010 Jun;25(2):254-62.

Facilitators to implementing rehab in the ICU Execute: design an intervention “toolkit” targeted at barriers - Tips: standardization, checks/reminders, & convenience Dedicated PT and OT in the MICU MICU tech assists PT & OT with patient mobilization Simple guidelines for PT & OT MICU consult Coordinator screens patients & prompts MD for PT referral Patients screened daily by PT/OT for mobilization activity Arch Phys Med Rehabil 2010;91:536-42.

Early ICU Rehab in Canada Canadian survey of ICU mobilization practices Rigorous survey of academic ICUs 311 respondents (117 PTs, 194 MDs), 71% response Knowledge gap: 69% of ICU clinicians underestimated the incidence of ICU-acquired weakness 39% of PTs reported inadequate education for ICU mobility Koo, KY. 2012. Open Access Dissertations and Theses. Paper 7499.

Barriers to Early ICU Rehab Institutional Lack of guidelines/ protocols – 58% Insufficient equipment – 51% MD orders required – 41% Provider Limited staffing – PTs – 78%; RNs - 59% Safety concerns – 64% Delayed ID to start rehab by MDs – 63%; RNs – 58% Patient Medical stability – 83% Excessive sedation – 60% Risk of device / line dislodgement – 42% Koo, KY. 2012. Open Access Dissertations and Theses. Paper 7499.

What are opportunities for interdisciplinary ICU rehab kt activities? Learning Objective 3: What are opportunities for interdisciplinary ICU rehab kt activities?

Projected incidence of non-cardiac surgery, mechanically ventilated adults More ICU survivors at risk for post-ICU impairments 40% Needham et al., Crit Care Med. 2005. 33(3):574-9.

Interdisciplinary Quality Improvement Projects

Barriers/Facilitators to Monitor Knowledge Use Sustain Evaluate Outcomes Adapt to Local Context Assess Barriers/Facilitators to Knowledge Use Select, Tailor, Implement Interventions Identify Problem Identify, Review, Select Knowledge Products/ Tools Synthesis Knowledge Inquiry Tailoring Knowledge J Cont Ed Hlth Prof. 2006. 26:13-24.

Barriers/Facilitators to Monitor Knowledge Use Sustain Evaluate Outcomes Adapt to Local Context Assess Barriers/Facilitators to Knowledge Use Select, Tailor, Implement Interventions Identify Problem Identify, Review, Select Knowledge Products/ Tools Synthesis Knowledge Inquiry Tailoring Knowledge

Quality improvement exemplar: Top Stroke Rehabil 2010;17(4):271–281. Quality improvement exemplar: Arch Phys Med Rehabil 2010;91:536-42. Additional information:

Structured KT and early ICU rehab implementation Results of Johns Hopkins MICU Rehab QI Project: Staffing: ↑ PT consults: 59% vs. 93% of pts (p=0.04) Staffing: ↓ ICU days with no PT/OT: 41% vs. 7% (p=0.004) Sedation: Significant ↓ in sedative drug use & deep sedation Median Narc: 71 v. 24 mg/day (p=0.01), Benzo: 47 v. 15 mg/day (p=0.09) MICU days alert: 30 v. 67% (p<0.001) No difference in pain scale (0-10): 0.6 v. 0.6 (p=0.79) Benefits: More ICU days without delirium No delirium: 21% vs 53% (p=0.003) Benefits: ↓ MICU & hosp LOS by 30% and 18%, respectively (p<0.03) Arch Phys Med Rehabil 2010;91:536-42.

4. Ensure all patients receive the interventions: Evaluate – ICU LOS Lord et al. Critical Care Medicine. 2013. 41(3):717-24.

4. Ensure all patients receive the interventions: Evaluate – Hospital LOS Projected Net Cost savings for 900 admissions/ yr: $817,836 22% reduction in ICU LOS 19% reduction in floor LOS Lord et al. Critical Care Medicine. 2013. 41(3):717-24.

Strengths and Limitations of QI approach Interdisciplinary team approach Rigorous data collection Complements Knowledge to Action Model with specific implementation steps Before-after study design Specific identification of “active ingredients”

Interdisciplinary Primary Research in Critical Care Rehabilitation

Slide courtesy of Dr. Margaret Herridge

Interprofessional Collaborations with RECOVER PROGRAM Slide courtesy of Dr. Margaret Herridge

Intensive Care Rehabilitation Study Barriers to Early Rehab in the ICU: A Delphi Study Develop theory-based “library” of barriers and facilitators to early rehabilitation in mechanically ventilated patients Study of nurses, physical therapists, physicians and respiratory therapists Mixed methods Semi-structured, theory guided interviews Iterative quantitative survey to establish stability of responses (Delphi) Slide courtesy of Drs. S. Goddard and B. Cuthbertson, Sunnybrook Health Sciences

CIHR Knowledge Synthesis Grant: Neuromuscular Electrical Stimulation in the ICU To conduct a systematic review of the benefits and risks of NMES for adults receiving mechanical ventilation in the ICU To summarize the strengths and weaknesses of studies included in the systematic review in terms of research methodology and research conduct To engage knowledge users: To identify and rank clinically important outcomes for the systematic review a-priori Using the results of the systematic review: To assess the suitability of NMES for clinical practice To identify future research opportunities for NMES in the ICU

Biking towards the future: the CYCLE Program of Research

CYCLE: Critical Care Cycling to Improve Lower Extremity Strength TryCYCLE: Phase II open label study 1 center, 33 pt prospective cohort Design the intervention; select outcomes; assess fidelity, safety, satisfaction, and acceptability CYCLE Preparation phase Survey development: pt, family, clinician satisfaction with rehabilitation CYCLE pilot: Phase II randomized pilot 6 center, 50 pt pilot RCT Feasibility, mechanisms CYCLE RCT: Phase III randomized trial Multicenter RCT BICYCLE Behavioural Intervention for Knowledge Translation CYCLE$ Economic evaluation Retrospective chart audit CYCLE-R Systematic Review Uni-CYCLE ICAN Rehab

CYCLE: Critical Care Cycling to Improve Lower Extremity Strength TryCYCLE: Phase II open label study 1 center, 33 pt prospective cohort Design the intervention; select outcomes; assess fidelity, safety, satisfaction, and acceptability CYCLE Preparation phase Survey development: pt, family, clinician satisfaction with rehabilitation CYCLE pilot: Phase II randomized pilot 6 center, 50 pt pilot RCT Feasibility, mechanisms CYCLE RCT: Phase III randomized trial Multicenter RCT BICYCLE Behavioural Intervention for Knowledge Translation CYCLE$ Economic evaluation Retrospective chart audit CYCLE-R Systematic Review Uni-CYCLE ICAN Rehab

Safety Outcomes Cycling session termination: The a priori safety event rate is low (0 to 4%). Adverse events: The intravascular catheter or indwelling tube dislodgement rate is low (<4%). Stability: Patients will tolerate in-bed cycling while critically ill.

Feasibility Outcomes Consent: The consent rate is high (70%). Intervention delivery: The daily research session delivery rate is high (>80%). Outcome measures: Physical outcome measures are successfully performed in a high proportion of assessable patients

Additional Interdisciplinary KT activities Occupational therapy examples Activities of daily living Cognitive interventions Communication Improve coping / locus of control Psychology examples Anxiety management Psychiatry, Speech Language Pathology, Recreation Therapy, and many others

Learning Objectives Understand the state of current best evidence for interdisciplinary rehabilitation in the ICU Understand barriers and facilitators to providing rehabilitation in the ICU Identify opportunities for interdisciplinary ICU KT activities Email: khome@mcmaster.ca